O&T: Spine Flashcards
Spine function
- Protect spinal cord
- Transfer loads (through disc, facet joints)
- Trunk support (through muscle attachments)
- Motion (flexion / extension, lateral flexion, rotation)
- Chest wall attachment (e.g. ribs, musculature to maintain respiratory function)
Neck / Low back pain
- Low back pain most disabling
- Prevalence up to 83% in one’s lifetime
- Musculoskeletal issues are highest burden in terms of global disease
- 20% patients seen in GP complains of back / neck problems
Back pain:
- Mostly benign
—> 60% subside in 1 week
—> 90% in 6 weeks
—> 95% in 12 weeks
- Variable severity
Approach to Back pain
- Identify cause
- Rule out sinister condition
- Localise source of pain by P/E
- Guide appropriate investigations + treatment
***DDx of Back pain
Mechanical pain (97%):
1. Back sprain (>70%)
2. Lumbar disc degeneration
3. Lumbar disc herniation
4. Spondylolisthesis
5. Fracture
- Vertebral body
- Spondylolysis
Non-mechanical (3%):
1. Neoplasia
2. Inflammatory arthritis (AS / Spondyloarthropathy)
3. Infection
4. Non-spinal diseases
- Pelvic inflammatory disease
- Endometriosis
- Nephrolithiasis, Pyelonephritis
- Aortic aneurysm
Common causes:
1. Myofascial sprain
- heals quick ~4 weeks
- by strenuous activity
- avoid provocative activity
2. Facet joint degeneration (back pain + referred pain)
3. Disc degeneration
- outer annulus of disc
- facet joint capsule
- chemical and mechanical irritation of nerve root
***History taking of Back pain
- Onset
- Acute (<1 month): fracture, infection
- Subacute (1-2 months): tumour, infection (e.g. TB)
- Chronic (>3-6 months): degenerative, claudication - Radiation / Leg pain
- Lower back to paraspinal musculature, SI joint, buttocks, posterior thigh
- Extension below knee —> indicate ***nerve root is involved —> follows dermatome - Mechanical vs Inflammatory
- Mechanical: pain when moving
- Inflammatory: pain at rest, improve with moving - Aggravating factors
- Heavy exertion, repetitively bending, twisting, heavy lifting
- Pain on lumbar flexion (disc herniation)
- Pain on extension and rotation / lateral flexion (facet joint)
- Pain on walking / leg symptoms (**spinal claudication / **spinal stenosis) - Night pain (sinister)
- Neurological deficit
- **Claudication distance (indicate severity)
- **Sciatica (Radicular pain)
- Numbness
- Weakness
- Unsteady gait (in severe motor deficit / cord compression resulting in proprioceptive loss)
- Sphincter control - Constitutional symptoms (fever, weight loss, appetite loss)
- Previous treatment (e.g. Failed back syndrome: chronic pain following back surgeries)
Other history:
9. Age (inflammatory, sarcopenia)
10. Smoking, DM, Immunosuppression, Drug abuse
11. Malignancy (past / family history)
12. Degree of limitation of pain (work, sleep)
13. Psychological state / emotional distress
**Red flag signs:
Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, **Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain
Claudication vs Sciatica vs Radiculopathy
Claudication / Neurogenic claudication:
- Usually refer to **Spinal stenosis
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- **Upright standing / ***Walk certain distance —> develop burning / numbness / pain in lower limbs —> usually cannot tell exact dermatomal location (usually vague sensation)
(Vascular claudication:
- Calf spasms (vs Burning / Numbness pain)
- Relieved by resting (vs Flexion in neurogenic claudication)
- Atrophic changes in toes, loss of hair
- Loss of pulses)
Sciatica:
- Pain radiating down the leg
- Radicular pain in certain distribution (e.g. calf, foot dorsum)
Radiculopathy:
- Pain related to single nerve root —> single dermatome
- Pain on walking / certain positions (e.g. sitting, flexion)
- Indicate ***disc pathology causing spinal stenosis
NB:
1. Can have both sciatica and claudication at the same time in nerve root compression
2. There is NO lumbar myelopathy (∵ cauda equina —> all are nerve roots)
***Red flag signs
Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, ***Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain
***P/E of Spine
Look:
1. Deformity
- Standing posture
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis - ***Listing
- Herniation lateral to nerve root (compressing on “shoulder” of nerve root) —> lean to contralateral side
- Herniation medial to nerve root (compressing on “axilla” of nerve root) —> lean to ipsilateral side - Muscle atrophy (indicate chronicity ∵ denervation of muscle)
- ***Modified Schober test
- Assessment of spine movement (Flexibility)
- Disc herniation will cause limitation in flexion - ***Gait (may indicate cord compression)
Feel:
1. Tenderness
- Muscle
- Spinous process
- SI joint
- Hip
- Tone (UMN vs LMN lesion)
Move:
1. ROM
- Forward flexion / extension
- Lateral flexion
- Neurology
- Motor
- Sensory
- Reflex
Special test:
1. **Straight leg raise test / Lasegue test / Bowstring test
- Patient lying supine —> Passive elevate leg in a straight leg —> stretch **sciatic nerve (L4-S3) —> pain (Normal: 70o) (positive: radicular dermatomal pain, same type of pain as patient’s experience, <70o)
—> **Cross straight leg raise test —> lift contralateral normal leg —> pain in problem side (∵ pulling of involved nerve root against axillary / posteromedial compression, negative in shoulder / far lateral compression)
—> **Lasegue test (confirmation test) —> lower leg a bit until no pain —> passive dorsiflex ankle to reproduce pain
—> ***Bowstring test —> gradually flex knee until no pain —> compress on popliteal fossa to reproduce pain (Alternative: 90o flex hip, 90o flex knee, extend knee until pain, drop a bit then compress on popliteal fossa)
- Femoral nerve stretch test
- Prone position —> Hip extension —> stretch ***femoral nerve (L2-L4) - Circulation (Vascular problems can always mimic spinal problems)
***Investigations of Back pain
Infection:
1. WBC
2. ESR (high blood fibrinogen causes RBC to stick to each other) (chronic cause)
3. CRP (6-8 hours after onset of infection) (acute cause)
Burn turnover markers (Malignancy):
4. ALP
5. Globulin
6. CaPO4
Malignancy:
7. Serum protein electrophoresis (Multiple myeloma)
8. Tumour markers (e.g. CEA, CA19.9, PSA)
Imaging
- Treat symptoms not images
- Imaging should be confirmatory tests
- Must explain to patients the reason for MRI
- X-ray
- correlation with symptoms
- positive history
- malignancy and infection
- false assurance? (False negative ∵ not completely sensitive to diseases esp. in early stages) - CT
- assess fracture configuration - CT myelogram
- MRI
- assess disc, soft tissue, canal pathologies
- nerve compression
- sinister pathologies (e.g. tumours, infection)
- confirmation of lesions
***Interpret X-ray of Spine
- Alignment
AP view:
- Spinous process (rotation / malalignment, scoliosis)
- Lateral edge of Vertebral body (laterolisthesis)
Lateral view:
- Anterior longitudinal ligament (spondylolisthesis)
- Posterior longitudinal ligament (retrolisthesis)
- Spinal laminar line
- Spinous process
- Normal curvature of spine (Lordosis, Kyphosis)
- Bone
- Size + Height
- Vertebral body (↑ size from cranial to caudal in lumbar spine)
- ***Pedicles (erosions may indicate metastasis)
- Transverse process (attachment of psoas, if psoas pull too hard —> transverse process fracture)
- Spinous process - Collapse
- Disc space
- Smooth
- Largest on L4/5 —> L5/S1 —> L3/4 - End plates
- Smooth - Foramen (Lateral view)
- Girdle (SI joint)
- Erosion / Fusion
- Sclerosis line - Height
- Iliopsoas shadow
- Tumour / Abscess / Haematoma can disrupt outline - Interarticularis (below pedicle of each level)
- Discogenic back pain
- Back pain caused by disc herniation
- Worse in forward ***flexion postures
—> Sitting
—> Bend forward to tie shoes
Pathophysiology of Disc herniation:
Rim lesion
—> Annulus tear
—> Lose ability to absorb shock
—> Shortened disc space
—> Herniated nucleus pulposus
—> Herniated content go into spinal canal
—> Nerve compression + Leg symptoms
Pain caused by:
1. **Biomechanical problems (Modic changes —> instability of spine)
2. **Cytokine release (Inflammatory)
3. ***Ingrowth of nerve and vasculature to the disc after annular tear
Features on X-ray:
- Disc space narrowing
Features on MRI:
- **High intensity zone in disc (inflammatory lesions at anterior / posterior aspect of annulus —> indicate **annulus fissure)
- ***Darker disc (degenerated disc)
- Posterior annulus fissure
- Compression of nerve root
Treatment:
Conservative:
1. Avoid flexion posture
2. Injection of LA in area of annulus tear to reduce pain —> but controversial since puncture can lead to more damage / degeneration of annulus
Surgery:
1. Decompression (RFA to cut away protruded segment of disc —> but do not treat pathology —> if heavy loading again disc can still progress to prolapse)
2. Spinal fusion
- Facet joints
- 2 Facet joints per spinal segment
- Sliding joints with ***lots of nerve fibres (dorsal rami of spinal nerve)
Facet joint arthrosis:
- Pain on **extension
- **Lateral extension for side of facet joint arthrosis
- Indicates overload of facet joints —> part of **Disc degenerative cascade (Disease origin at the **disc —> degeneration of disc —> overload facet joint —> ***spondylolisthesis)
- Bright signal in T2 weighted MRI due to edema
Hypertrophy of facet joint:
- ***Narrowing of intervertebral foramen
Treatment:
1. Back muscle strengthening
2. Facet joint injections of LA / Steroids
- Spondylolysis
***Pars interarticularis defect / fracture —> discontinuation of adjacent vertebra
Clinical features:
1. LBP with insidious onset (can be acute if acute hyperextension (e.g. diving, weight lifting, gymnastic))
2. Radicular symptoms only with **Spondylolisthesis (only in severe case will Spondylolysis develop into Spondylolisthesis) (Pars defect alone does not compress nerve root)
3. **Hamstring spasm (flexed hips + knees)
4. Shortened stride length
5. ***Flattened lordosis
Investigations:
1. X-ray
- Oblique view for “Scotty dog” appearance: break in pars —> break in dog’s neck
2. Single photon emission CT (SPECT): increased radionuclide uptake as stress reaction
3. CT
4. MRI
End-stage degeneration:
- **Spondylolisthesis
—> Radiological instability
—> **Spinal stenosis by kinking centrally / compression by superior articular process impingement at foramen / excessive movement can also cause osteophytes, ligamentum flavum hypertrophy
Treatment:
1. Rehabilitation
- core strengthening to prevent progression
- Protect in acute cases
- bracing
- activity avoidance
- resume all activities once symptoms resolve - Surgery
- rarely needed
- stabilise spine
- high grade slips in adolescents
- non-union fracture
- neurological symptoms
Spondylolisthesis
Many types / causes:
1. Degenerative of facet joints (elderly)
2. Spondylolysis (younger)
Etc.
Causes: (SpC Revision)
1. Dysplastic (Congenital malformations)
2. Isthmic (i.e. Pars fracture) (Stress fracture in gymnast who arches back a lot, Elongation of pars due to various reasons) (common, can slip >25%)
3. Degenerative (Loss of disc height: usually only minor slip <25%)
4. Traumatic
5. Pathologic (Pagets, Metastatic disease)
6. Iatrogenic (After surgical excision)
- Spinal stenosis
Spinal canal narrowing with possible ***nerve root compression
Causes:
1. IV disc herniation (but with positive SLR test (self notes))
2. Osteophytes
3. Facet joint hypertrophy
4. Ligamentum flavum hypertrophy
Clinical features:
1. **Neurogenic claudication
- **Walking increases severity of burning / aching pain, numbness (dermatomal), paresthesia, subjective / objective weakness
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- Burning / Numbness in lower limbs
2. Leg / Back pain
3. **Motor deficit
4. **Sensory disturbance
5. Reflex alterations
6. ***SLR test negative (SpC Revision)
7. Lots of symptoms but no signs on examination (e.g. -ve SLR test) (SpC Revision)
Cauda equina syndrome:
- Severe stenosis
- **Acute LBP
- **Sciatica
- **Saddle paresthesia
- LL weakness
- Gait dysfunction
- **Sphincter incontinence
- Bimodal distribution:
—> Young: Large central disc herniation (after acute trauma)
—> Elderly: Chronic deterioration of spinal stenosis
Treatment:
1. Surgery
- Dural sac + Nerve root decompression —> target cause of stenosis
